Medical Student Pacific Northwest University Ocala, Florida
Case Diagnosis: A 23-year-old male with complex partial status epilepticus
Case Description or Program Description: A 23-year-old incarcerated male with history of amphetamine overdose, past suicidal attempts, and epilepsy had an episode of seizure-like activity just prior to being discharged. It appeared that he had impaired consciousness, ictal eye closure and sustained myoclonus of all 4 extremities. This later transitioned into status epilepticus and led to the administration of lorazepam and Keppra. Throughout the episode, medical staff was evaluating for psychogenic nonepileptic seizure (PNES) and malingering. In this rural setting, EEG and neurologists are not accessible. An ABG was collected and resulted in a normal pH. Due to his unresponsiveness, he was later intubated by anesthesia. He later safely recovered and was able to be discharged back to his correctional facility.
Setting: Rural Public Hospital
Assessment/Results: Based on his epileptic history and unresponsiveness, the event was inconclusively diagnosed as complex partial status epilepticus.
Discussion (relevance): To minimize misdiagnosis and to prevent inappropriate long-term treatments of anti-seizure medications in rural settings where EEG is not available, we recommend several diagnostic protocols that are readily available in most hospital settings. Serum prolactin, creatine phosphokinase, and lactate should be measured soon after an episode as elevated levels can indicate epileptic seizure occurrence. Physical exam findings of ictal eye closure with resistance to eye opening during spells are inconsistent with epileptic seizures. Hand drop test over a patient’s face to look for avoidance of hand fall may be found in psychogenic patients. Finally, corneal reflexes and plantar reflexes will be intact in psychogenic causes.
Conclusions: In rural settings where EEG is not available, it is crucial to know alternatives.
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